PATIENT INFORMATION (CHILD)
Name:
First Name
Middle Initial
Last Name
Nickname:
DOB:
-
Month
-
Day
Year
Date
Age:
Gender
Male
Female
Prefer not to say
Residence Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Has any member of your family been a patient at this office before?
Yes
No
If yes, Please name them:
How did you hear about our office?
FAMILY RECORD
Parent/Guardian 1 Full Name
*
Relationship to Patient:
*
Parent
Step-Parent
Guardian
DOB:
*
-
Month
-
Day
Year
Date
Sex:
*
M
F
Address (if different)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Cell Phone:
*
Format: (000) 000-0000.
Marital status:
Email:
*
example@example.com
Parent/Guardian 2 Full Name
Relationship to Patient:
Parent
Step-Parent
Guardian
DOB:
-
Month
-
Day
Year
Date
Sex:
M
F
Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Cell Phone:
Format: (000) 000-0000.
Marital Status:
Email:
example@example.com
ORTHODONTIC INSURANCE
Primary Insurance Company:
Subscriber Name:
DOB:
-
Month
-
Day
Year
Date
Phone #:
Format: (000) 000-0000.
Group #:
Member ID #:
Relation to Subscriber:
Self
Parent
Guardian
Other
Secondary Dental Insurance (If Applicable)
Subscriber Name:
DOB:
-
Month
-
Day
Year
Date
Phone #:
Format: (000) 000-0000.
Group #:
Member ID #:
Relation to Subscriber:
Self
Parent
Guardian
Other
MEDICAL HISTORY
Has the patient ever had any of the following medical conditions or problems?
Asthma
Liver Disease/Hepatitis
Hearing Impairment
Diabetes
Kidney Disorder
Rheumatic Fever
Migraines
Congenital Heart Defect
HIV+/Aids
Growth Disorders
Heart Murmur
Cancer
Epilepsy/Seizures
Latex Allergy
Tuberculosis
Osteoporosis/Osteopenia
Blood Disorder/Anemia
Nickel Allergy
NO NONE OF THESE APPLY
If yes, please explain below:
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Primary Physician's Name:
Date of last visit:
Phone #:
Medical Record # (Kaiser):
Is the patient presently under the care of a physician for any medical problem or condition?
Yes
No
If yes, please specify:
Is the patient currently taking any prescription medications?
Yes
No
If yes, please list names and dosages:
Does the patient have any neurodevelopmental, learning, or behavioral conditions (e.g., ADHD, autism, anxiety)
Yes
No
If yes, please describe any accommodations or considerations:
Please describe any allergies/medical problems the patient has:
Has the patient ever been hospitalized or had surgery?
Yes
No
If yes, please specify
DENTAL HISTORY
Former or Current Dentist:
Approximate date of last visit:
Does the patient have a previous history of orthodontic treatment?
Yes
No
If yes, with whom and when?
Has an orthodontist been consulted previously?
Yes
No
Who?
CHECK ALL THAT APPLY
Please check all that apply to your child:
Suck their thumb/finger?
Bite his/her nails or hard objects?
Suck/bite their lips?
Speech problems or speech therapy?
Mouth breather?
Tongue thrust habits?
Grind/clench their teeth?
Missing Teeth?
TMJ/Jaw clicking pain?
Snoring/sleep apnea?
NONE OF THESE APPLY
WHAT WOULD YOU LIKE ORTHODONTIC TREATMENT TO ACCOMPLISH?
I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that this information will be kept confidential, and I agree to notify this office of any changes in my child's medical or dental health.
Parent/Guardian Signature:
Date
-
Month
-
Day
Year
Date
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